DEPARTMENT OF HEALTH CARE FINANCE

DEPARTMENT OF HEALTH CARE FINANCE Dear Provider: Enclosed is the District of Columbia Medicaid provider enrollment application solely used for providers, who request to be considered for the Adult Substance Abuse Rehabilitative Services Program. Please complete the application packet in its entirety including the Required Documents Checklist. Failure to include signatures on all forms and copies of all necessary attachments will delay the processing of your application. Return the completed and signed application and applicable documents to: Department of Health Care Finance Health Care Operations Administration Attn: Provider Enrollment and Outreach Branch One Judiciary Square 441 4 th Street NW Suite 1000S Washington, DC 20001 After receipt and approval of your application, you will be notified by mail of your District of Columbia Medicaid provider number. If you have any questions regarding this enrollment packet, please call the Provider Enrollment and Outreach Branch at 202-698-2000. Sincerely, Provider Enrollment and Outreach Branch Division of Public and Private Provider Services Health Care Operations Administration

DEPARTMENT OF HEALTH CARE FINANCE Adult Substance Abuse Rehabilitative Services (ASARS) Program Provider Enrollment Application Checklist Required Documents W-9 DC Medicaid Provider Agreement Disclosure of Ownership Form Verification of Liability Insurance Copy of APRA Certification Verification of NPI and Taxonomy Code

DEPARTMENT OF HEALTH CARE FINANCE MEDICAID PROVIDER APPLICATION FORM Please type or print. Incomplete applications will not be processed. Please do not remove any pages from this application. SECTION I APPLICANT INFORMATION Check the appropriate box below and complete the associated information. ο Individual Name (Last, First, Middle) Doing Business as Telephone Fax Email ο Group or Hospital Group or Name Doing Business as Contact Name Telephone Fax Email Have you ever enrolled in DC Medicaid? ο Yes ο No If Yes, please complete the following: DC Medicaid Provider Number SECTION II PROFESSIONAL LICENSURE List all current professional licenses. Please attach copies. State Type Number Issue Date Expiration Date State Type Number Issue Date Expiration Date State Type Number Issue Date Expiration Date

SECTION III OFFICE INFORMATION Office Street Address City/State/Zip Ward Office Telephone(s) Office Fax Office Email Office Manager Correspondence Address City/State/Zip Type of Practice (LLC, Corp, etc.) Group/Corporate Name Federal Tax ID Medicare # National Provider ID # Taxonomy Code Correspondence Address City/State/Zip Billing Indicator: SECTION IV BILLING INFORMATION Payment Address City/State/Zip Remittance Address City/State/Zip What type of media are you using for billing today (i.e., electronic, manual, etc.)? Do you bill for diagnostic radiology or clinical laboratory services under your supervision? ο Yes ο No If Yes, please indicate the following: ο Radiology or ionizing services Clinical laboratory services CLIA#

DEPARTMENT OF HEALTH CARE FINANCE MEDICAID PROVIDER AGREEMENT Name of Provider Address Title XIX Provider Number This Agreement, made and entered into this day of, 20, by and between the District of Columbia Department of Health Care Finance, hereinafter designated as the Department, and the above-named, a Provider of Services, whose address is, as stated above, hereinafter designated as the Provider. Witnesseth: WHEREAS, persons receiving public assistance payments from the Department of Health Care Finance and other persons eligible for care and under the Medical Assistance Program operating under Title XIX of the Social Security Act, are in need of medical care; WHEREAS, Section 1902(a) (27) of Title XIX of the Social Security Act requires the District of Columbia to enter into written agreement with every person or institution providing services under the State s Plan for Medical Assistance (Title XIX); WHEREAS, pursuant to the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code 7-771.01 et seq.) which makes the DC Department of Health Care Finance the agency responsible for administering the Medical Assistance Program (Title XIX) in the District of Columbia, and authorizes the Department of Health Care Finance to take all necessary steps for the proper and efficient administration of the District of Columbia Medical Assistance Program; WHEREAS, to participate in the District of Columbia Medical Assistance Program, the provider when applicable, must: (1) be licensed in the jurisdiction where located and/or the District of Columbia; (2) be currently in compliance with standards for licensure; (3) services be administered by a licensed or certified practitioner; and, (4) comply with applicable Federal and district standards for participation in Title XIX of the Social Security Act, and; WHEREAS, prospective provider has filed an application with the Department to provide medical services to persons eligible under the Medical Assistance Program operated under Title XIX of the Social Security Act and said application is incorporated by reference into this Agreement and made a part hereof the same as if it were written herein.

The Provider agrees: I. GENERAL PROVISIONS A. To provide to Medicaid patients, who also qualify as Medicare crossover beneficiaries, services as covered in Title XIX of the Social Security Act and the State Plan of Medical Assistance. B. To accept as payment for supplying the services in A above, a reimbursement rate calculated in accordance with the District State Plan for Medical Assistance; 1. The provider s payment shall be accepted as payment in full for the care of the patient, and; 2. No additional charge shall be imposed on the patient, member of his family or to another source for any supplementation for any time except as allowed within Federal and District regulation. C. To satisfy all requirements of the Social Security Act, as amended, and be in full compliance with the standards prescribed by Federal and State standards. D. To accept such amendments, modifications or changes in the program made necessary by amendments, modifications or changes in the Federal or State standards for participation. E. To comply with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, 42 CFR Parts 80, 84 and 90, the Americans with Disabilities Act, P.L. 101-336, any amendments thereto and the rules and regulations there under. F. To maintain all records relevant to this Agreement at his/her cost, for a period of six years or until all audits are completed, whichever is longer. Such records shall include all physical records originated or prepared pursuant to performance under this Agreement, including but not limited to, financial records, medical records, charts and other documents pertaining to costs, payments received and made, and services provided to cover Medicaid recipients. G. To provide full access to these records to authorized personnel of the Department, the United States Department of Health and Human Services, the Comptroller General of the United States or any of their duly authorized representatives for audit purposes. H. To furnish upon request to the Medicaid agency, the Federal Government or their designees, information related to business transactions in accordance with 42 CFR & 455 105(b); I. To hold harmless the District of Columbia Government, the Department and Medicaid recipients against any loss, damage, expense and liability of any kind arising out of any action of the provider or its subcontractors arising out the performance of this agreement. J. To comply with the advance directive requirements contained in 42 CFR, Part 489, Subpart I, as appropriate. K. To complete and sign a Provider Application to participate in the Medical Assistance Program (Title XIX), and to keep the information in the application current with the

understanding that the application becomes a part of this agreement and that each succeeding change in the application constitutes an amendment to the Agreement and failure to keep the information current constitutes a breach of the Agreement. a. To provide assurances of compliance with: D.C. Law 12-238 which prohibits Medicaid providers from offering employment or contracting with any person who is not a licensed healthcare professional until a criminal background check has been conducted for the person and also prohibits any facility from employing or contracting with any person who has been convicted of certain criminal offenses specified in the law; 42 USC 31306 and 49 CFR 382 which requires employers of commercial drivers to conduct pre-employment, reasonable suspicion, and post-accident testing for controlled substances; and, The Drug-Free Work Place Act of 1988 (21 USC 701 et seq.), which requires the implementation of an alcohol and drug-testing program. b. That any breach of violation of any one of the above provisions shall make this entire Agreement, at the Department s option, subject to immediate cancellation or imposition of enforcement remedies in conformance with Federal and District laws and regulations. II. REQUIRED INFORMATION: A. The address of all sites at which services will be provided to Medicaid beneficiaries who qualify as Medicare crossover beneficiaries; B. A completed provider application including submission of the W9 form; C. A copy of the professional or business license (if individual or group); D. A copy of the hospital license (if a hospital); E. Proof of liability insurance; F. The submission of any other documentation deemed necessary by the Department for the approval process as a Medicaid Provider. III. CONTRACT AND SUBCONTRACTS A. The Department or the provider may terminate this Agreement for convenience by giving 90 days written notice or intent to terminate the Agreement to the party. B. The provider shall be legally responsible for all activities of its contractor and subcontractors and for requiring that they conform to the provisions of this Agreement. Subject to such conditions any service or function required by the provider pursuant to this Agreement may be subcontracted to any person or organization who/which meets all Federal and District requirements for participation in Medicaid, whether or not they are enrolled as Medicaid providers. C. Sub-contractual agreement with providers who have been convicted of certain crimes or received certain sanctions as specified in Section 1128 of the Social Security Act is prohibited. Services provided to Medicaid beneficiaries, who qualify also as Medicare

crossover beneficiaries, through such subcontracts shall not be eligible for reimbursement by the Department. D. The Department reserves the right to require the Provider to furnish information relating to the ownership of the subcontractor, the subcontractor s ability to carry out the proposed obligations, assurances that the subcontractor shall comply with all applicable provisions of Federal and District law, and regulations pertaining to Title XIX of the Social Security Act and the State Plan for Medical Assistance and with all Federal and District laws and regulations applicable to the service or activity covered by the contract; the procedures to be followed by the provider in monitoring or coordinating the subcontractor s activities and such other provisions as the Department or the Federal Government may reasonably require. E. Each subcontract shall contain a provision that the subcontractor shall look solely to the provider for payment of covered services rendered IV. PAYMENT TO PROVIDER A. The Department shall reimburse providers for services to Medicaid beneficiaries, who qualify also as Medicare crossover beneficiaries, in accordance with the District s State Plan of Medical Assistance. B. The provider shall submit invoices for payment according to the Department s requirements. C. The Department shall make payments to the provider in accordance with applicable laws, as promptly and as feasible after a proper claim is submitted and approved. D. The Department shall notify the provider of any major changes in Title XIX rules and regulations and in the State Plan of Medical Assistance. E. The provider shall not bill the patient for any part of care or treatment. V. THIRD PARTY LIABILITY RECOVERY A. The provider shall utilize and require its subcontractors to utilize, when available, covered medical and hospital services or payments from other public or private sources, including Medicare. B. The provider shall attempt to recover, and shall require its subcontractors to attempt to recover, monies from third party liability cases involving workers compensation, accidental injury insurance and other subrogation of benefit settlements. C. The Department shall notify the provider of any reported third party payment sources. D. The provider shall verify third party payment sources directly, when appropriate. E. Payment of State and Federal funds under the District s State Plan for Medical Assistance to the provider shall be conditional upon the utilization of all benefits available from such payment sources.

F. Each third party collection by a provider for a Medicaid recipient shall be reported to the Department and all recovered monies shall be returned to the Department immediately upon recovery. VI. SANCTIONS FOR NON-COMPLIANCE If the Department determines that a provider has failed to comply with the applicable Federal or District law or rule, or any law or order that prohibits discrimination on the basis of race, age, sex, national origin, marital status or physical or mental handicap, the Department may do all of the following: A. Withhold all or part of the providers payments; and/or, B. Terminate the Agreement within 30 days from date of notice to the provider. C. Before taking action described in VI, A & B, the Department shall provide written notice to the provider which shall include: 1. Identification of the sanction to be applied; 2. The basis for the Department s determination that the sanction should be taken; 3. The effective date of the sanction; and, 4. The timeframe and procedure for the provider to appeal the Department s determination. D. The termination of the Agreement shall not discharge the responsibilities of either party with respect to services or items furnished prior to termination, including retention of records and verification of overpayment or underpayment. E. Upon termination, the provider shall submit to the Department all outstanding invoices for allowable services rendered prior to the date of termination in the form prescribed by the Department. Invoices submitted not later than thirty (30) days following the termination date shall be paid. F. The provider also shall submit to the Department all financial performance and other reports required as a condition to this Agreement within ninety (90) days of the termination date. G. The Department reserves the right to terminate this Agreement immediately if: 1. The United States Department of Health and Human Services withdraws Federal financing participation in all or part for the cost of covered services; 2. District funds are unavailable for the continuation of the Agreement; 3. The Department is notified by the appropriate District agencies, or other appropriate licensing or certifying bodies that the licenses and/or certification under which it operates have been revoked, expired and/or will not be renewed; or, 4. The owners, officers, managers or other persons with substantial contractual relationships have been convicted of certain crimes or received certain sanctions as specified in Section 1128 of the Social Security Act.

H. The Department reserves the right to terminate this Agreement or take some other enforcement act consistent with Federal and District law and regulation in the event of default of the provider. I. The following shall trigger use of an enforcement action against a provider: 1. Inability of the provider to provide the services described in this Agreement; 2. Insolvency of the provider; 3. Failure of the provider to maintain its licensure or accreditation; 4. Violation of any provision of applicable Federal or District law or implementing rules. J. The provider shall be responsible for providing written notice to recipients thirty (30) days prior to the effective date of the termination in the form prescribed by the Department and shall be responsible for notifying the Department of those recipients who are undergoing treatment of an acute condition. K. The Department may, at its sole discretion, offer to re-negotiate any provision of this Agreement if such re-negotiation would mitigate or eliminate any of the causes of termination s specified. VII. ASSIGNMENT OF RIGHTS The rights, benefits and duties included under this Agreement shall not be assignable by the provider without receiving the written approval of the Department. The Department, as a condition of granting such approval, shall require that such assignees be subject to all conditions and provisions of this Agreement and all Federal laws and rules governing the assigned Agreement. VIII. TERMINATION OR REDUCTION OF THE DEPARTMENT S SOURCE OF FUNDING The Department s obligation to pay funds for the purpose of this Agreement is limited solely to availability of Federal and District funds for such purposes. No commitment is made by the Department to continue or expand such activities. IX. CONFIDENTIALITY OF INFORMATION A. All information, records and data collected and maintained by the provider or its subcontractor relating to eligible Medicaid recipients shall be protected by the provider from unauthorized disclosure; B. Except as otherwise provided in Federal law or rules, use or disclosure of information concerning recipients shall be restricted to purposes directly related with the administration of the Medicaid program; C. Purpose directly related to the Medicaid program shall include the following: 1. Establishing eligibility; 2. Providing services; and, 3. Conducting or assisting in an investigation, prosecution, civil or criminal proceeds relating to the administration of the Medicaid program.

X. EFFECTIVE DATE D. The type of information to be safeguarded shall include all information listed in 42 CFR 431.305. The effective date of agreement for provider payments shall be on the date the provider attains participating status as determined by the Department under Federal and District regulations, and that such determination shall be made a part of this Agreement. I agree that the receipt by the D.C. Medicaid program of the first and each succeeding claim for payment from me will be the Medicaid program s understanding of my declaration that the provisions of this Agreement and supplemental providers manuals and instructions have been understood and complied with: Provider s Signature Date Address Phone Number Signature of individuals responsible to enforce compliance with these conditions Chief Executive Officer (if applicable) Date Chief Medical Officer (if applicable) Date Principal Corporate Officer (if applicable) Date Accepted by: Authorized Signature by: Date Department of Health Care Finance For Official Use Only D.C. Medicaid Provider Number Assigned: